The "damning verdict" on the way Haringey council protects vulnerable children landed on Ed Balls' desk at nine o'clock yesterday morning.

In 14 pages, the Ofsted Chief Inspector, Christine Gilbert, revealed to the secretary of state for children "significant weakness" in the north London borough's methods of protecting children from abuse. She concluded, in restrained language, that management was "inadequate".

After reading its 57 critical paragraphs, Balls felt compelled to go further. He described the review as "devastating". Five years ago, national child protection policy was overhauled in the wake of the death of eight-year-old Victoria Climbié while she was in Haringey's care. Yesterday the borough's leadership was found to have ignored key recommendations following her death and was confronted with a list of systemic mistakes, oversights and examples of inadequate management.

Ofsted's report, produced with the Healthcare Commission and HM Inspectorate of Constabulary, found Haringey to have the worst child protection systems of any borough scrutinised by a review in the last 12 months. "This was not an investigation into the tragic death of 'Baby P', but it has shown that the serious concerns raised by his case, and the death of Victoria Climbié, remain," said Gilbert. "Haringey is clearly still not doing enough to ensure that children are properly protected."

The review took 13 days. Inspectors observed working life in a social care duty room, reviewed case files, including those of Baby P, held interviews, spoke to children and community representatives and considered performance data and the borough's policy on child protection.

Bureaucracy

The list of errors and malpractice discovered within the council and across local health agencies and the police, begins with the way officials handle the first sign that a child might be in danger.

The borough's handling of referrals, which might come from a police officer or teacher, is "generally poor". Information about cases is not gathered properly and the person who makes the referral is often not told what action has been taken within 48 hours, a recommendation after the Climbié case to make different agencies to talk to each other about cases.

Even when case files are opened, they are "inadequate", the review said. Entries are sometimes inaccurate and the distribution to partner agencies of minutes of important meetings where child protection measures are decided are frequently subject to "extreme delays".

The result is that vital action which could safeguard a vulnerable child may not be taken. Child protection plans are "generally poor" and often social workers have no idea of who is doing what when they are drawn up.

Communication

The quality of health assessment is "poor". Dr Saba Al Zayyat, who examined Baby P, missed his broken back. There is insufficient guidance for GPs who carry out most assessments. Some accident and emergency staff at the North Middlesex and Whittington hospitals, both locations where Baby P was treated, don't know how to check if a child is on the child protection register, the review found.

In further evidence that different agencies are not sharing information properly, police reports of children being caught up in incidents of domestic violence often arrive with social workers late.

Balls yesterday expressed concern that children are rarely interviewed by social workers about what is happening to them, and if they are, it is unclear from records whether they are on their own and therefore able to tell the truth about abuse they are suffering, or with their abusers.

Management

There was serious criticism of the management of child protection in Haringey. Sharon Shoesmith, who was yesterday "removed" from her post at Balls' insistence, was accused of "insufficient management oversight" over the assistant director of children's services. There was also insufficient supervision of front-line social workers by senior management.

The review concluded there was little evidence that the local safeguarding children board made life any safer for young people in the area and it failed to challenge the work of its members and frontline staff. A total of 51 of the 121 established social worker posts are filled by agency staff which "results in a lack of continuity for children and their families".

But for those demanding answers about what happened to Baby P, the review did not address his case directly. Ofsted said the case review into his death was "inadequate" and Balls ordered a fresh review to be published by the end of March. He resisted calls from the Conservatives and the Liberal Democrats to publish the full text of the existing review which, according to those who have read it, is "a litany of disaster".

"This two week investigation leaves a swath of questions unanswered," said Lynne Featherstone, Lib Dem MP for Hornsey and Wood Green. "I have never read anything as damning and devastatingly critical as this report is, but it looks at practice and management rather than the actual issues around Baby P and that is frustrating.

"There can be no halfway house when it comes to protecting our local children. Either Haringey council children's service is up the job or not and the report clearly shows not. It should be taken into full special measures now rather than after more reports."

Main Findings

• Failure to identify children at immediate risk and act on evidence

• Social workers, health professionals and police did not communicate well